Thanks for signing up! You might also like these other newsletters:

THURSDAY, July 19, 2012 — Four months after a 12-year-old died suddenly from an invasive bacterial strep infection, the New York City hospital where he was treated and discharged is changing its procedures to prevent similar tragedies from occurring.

“Following our review of the events that led to this tragic loss, we have implemented corrective actions and are in the process of designing additional care processes to address the delivery of care to our ED [emergency department] patients,” Langone Medical Center spokesperson Lisa Greiner said in a statement.

As Everyday Health reported in June, 12-year-old Rory Staunton fell desperately ill after a strain of toxic bacteria believed to be streptococcus pyogenes, or group A streptococci, entered his bloodstream through a cut on his elbow. Weak, vomiting, and complaining of severe leg pain, he was taken by his parents first to a pediatrician and then to the emergency room at New York University Langone Medical Center in lower Manhattan. There, the Stauntons say, doctors diagnosed him with a stomach bug and discharged him, even though they had yet to receive the results of his blood work, which showed, hours later, high levels of a type of white blood cell associated with bacterial infections.

The next night, Rory returned to the ER. This time, he was admitted. He died of toxic shock less than 48 hours later.

‘How Can We Do Better?’

In the months since, Rory’s story has sparked many questions about what, if anything, could have done differently to prevent his death. Several experts say that invasive strep infections like Rory's are difficult to diagnose and treat, and that some casualties are unavoidable. Critics question if Rory’s outcome could have been avoided by more stringent standards. NYU said it intends to address the second issue with changes to its emergency department protocol.

Among the changes, Greiner explained, is “a new ED Discharge Checklist to make certain that the treating physician and nurse conduct a final review of all critical lab results and patient vital signs prior to the patient being discharged."

Additionally, Greiner said, the attending ED physician will be immediately notified of lab test results suggesting serious infection, such as "elevated band counts" that indicate bacterial infection. Rory’s band count, the New York Times reported last week, was five times normal.

Such safety measures might seem obvious, but experts say they sometimes get lost in the high-stress environment of the ED.

“Unfortunately, in high-volume emergency departments, when there is so much going on … occasionally things can slip by,” says Corey Slovis, MD, head of the emergency department at Vanderbilt University Medical Center in Nashville, who was not acquainted with Rory's case. “You’re trying to provide safe, emergent care as rapidly as you can, and sometimes trying to go too fast can get you into trouble.”

To compensate for this, NYU Langone is also implementing a plan to relay important information post-discharge. “In the unlikely occurrence that a clinically relevant test is only available after the patient is discharged from the ED,” Greiner said, “the patient will be called and the information will be shared with the referring physician.”

Neither of these actions was taken in Rory’s case, the Times reports. The Stauntons were not informed of the lab results before or after leaving the hospital that first day. Nor was Rory’s pediatrician, who sent the family to the ED.

“It’s impossible to see more than 100 million patients a year in emergency departments in the United States and not have some mistakes, not have some suboptimal outcomes, not have errors that in retrospect could have been avoided,” Vanderbilt’s Dr. Slovis says. “I think the important thing is that we learn from our mistakes. That whenever an event occurs that is suboptimal, or truly a bad outcome, we [ask], ‘How can we do better?’”

NYU Langone’s proposed changes attempt to answer that question. “Keeping our patients safe is our first priority,” Greiner said in the hospital’s statement. “We want to prevent this situation from happening again.”

That’s what the Stauntons want, too. “There’s nothing out there for me. Rory isn’t coming back,” Ciaran Staunton said a few weeks after the tragedy. “But if our story helps save someone else’s son, maybe some good can come of this. Maybe we’ll be the last people to be tortured by the loss of a child to strep.”